Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Health Care Of Paradise during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including encephalopathy and anemia, had a physician order for Megestrol Suspension as an appetite stimulant to be given twice daily within specific time windows. During a morning med pass, an RN administered several medications but omitted the ordered Megestrol, later confirming it remained in the med cart and that the order had not been followed, despite facility policy requiring adherence to physician orders. In a separate case, a newly admitted resident with encephalopathy, multiple sclerosis, epilepsy, and dementia had hospital discharge instructions for a Neurology follow-up within one to two weeks, but the facility did not arrange this appointment, even though the admissions process requires reviewing discharge summaries and setting up needed follow-up care.
A resident with multiple chronic conditions was discharged without documented evidence that they were presented with or assisted in choosing among post-acute care providers, as required by their care plan. Staff interviews revealed that while a form existed for selecting the facility's preferred home health agency, there was no consistent documentation that residents were informed of other options or that their preferences were considered.
A facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident with a right hip fracture and syncope, whose Medicare Part A services ended. The resident was discharged without documented evidence of receiving the NOMNC letter, which was expected to be provided three days before the end of benefits. The facility's policy required the NOMNC to be delivered at least two days before services end, with the original signed document retained in the file.
The facility failed to implement care plan interventions for several residents, including the absence of an air mattress for a resident at risk for pressure ulcers, delayed midline dressing changes for two residents, lack of feeding assistance for two residents with malnutrition, and delayed enema administration for a resident with bowel care needs. These deficiencies indicate lapses in following prescribed care protocols.
A facility failed to accurately document care for residents, including the application of antimicrobial wipes, wound care, and midline dressing changes. For one resident, CHG wipes were not applied as ordered, and the RN documented care without verification. Two residents had discrepancies in wound care documentation, with dressings not changed as recorded. Midline dressing changes for two residents were also inaccurately documented, with observed dressings not matching recorded dates. These failures went against professional standards and could compromise patient safety.
Two residents in a facility were not provided with the required one-on-one feeding assistance despite physician orders and clear signage indicating the need. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and not seated in a chair as instructed, while another resident with severe malnutrition was incorrectly assumed to be independent in eating. The lack of adherence to feeding assistance orders placed both residents at risk for significant weight loss and malnutrition.
A resident with a multidrug-resistant fungal infection did not receive prescribed Chlorhexidine (CHG) wipes as ordered. The RN documented the application without verifying if CNAs performed the task, leading to discrepancies in the treatment administration record. The DON confirmed this was inappropriate and could be considered an alteration of medical records.
A facility failed to follow a physician's order for an air mattress for a resident at risk for pressure ulcers, and did not provide wound care as per orders for two residents. The air mattress was not delivered or placed, despite documentation indicating otherwise. Additionally, wound care treatments were missed and inaccurately documented, with staff pre-signing treatments that had not been administered. The Director of Nursing acknowledged the discrepancies and the unacceptable practice of signing off on unadministered treatments.
A resident with a history of ulcerative colitis and diverticulitis did not receive appropriate bowel care as per the facility's protocol. Despite a physician's order for a Fleet Enema on the fifth day without a bowel movement, the enema was not administered by the ninth day. The resident's family was not informed about the bowel protocol or the enema order, and the KUB test results were not provided upon request. The facility's failure to follow the bowel protocol led to a deficiency in care.
The facility failed to provide one-on-one feeding assistance for two residents, as ordered by physicians, leading to a risk of significant weight loss and malnutrition. One resident, with metabolic encephalopathy and dementia, was left with untouched meal trays and no staff assistance, despite being dependent on staff for eating. Another resident, with dementia and severe malnutrition, also did not receive the required assistance. The lack of compliance with feeding orders was not communicated to the Registered Dietician, potentially leading to significant weight loss.
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications. One resident had a midline catheter with no physician's clarification order, and the dressing was not changed as documented. Another resident's midline dressing was also not changed as documented, despite being used for IV administration. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed the facility followed the PICC Dressing Change policy.
A facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and intravenous midline catheter. Despite a physician's order for enhanced barrier precautions, a therapist did not wear a gown while providing care, only using gloves. This was confirmed by a registered nurse and the infection preventionist nurse, who stated that both gloves and gowns were required according to the facility's policy and CDC guidelines.
The facility failed to ensure proper dialysis care and communication for two residents, leading to potential cross-contamination, inadequate infection control, and lack of monitoring for dialysis-related complications.
The facility failed to obtain a physician order and implement a care plan for a resident's wrist splint. The resident was admitted with a wrist fracture and had a splint in place, but the necessary orders and care plan were not documented or transcribed, leading to the deficiency.
The facility failed to ensure a physician's order for IV insertion and care for a resident admitted with urinary tract infection, sepsis, and dehydration. The IV heplock was old and undated, and there was no documented evidence of a physician's order for the IV insertion or related care.
The facility failed to follow the physician's order for a resident's oxygen administration, resulting in the resident receiving 4 LPM instead of the prescribed 2 LPM. The order lacked clarity on whether the O2 should be continuous or as needed, and titration parameters were not specified. Both the RN and DON acknowledged the oversight.
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 6.25%. One incident involved a nurse administering a standard iron tablet instead of the prescribed delayed-release form, and another involved a nurse applying only one Lidocaine patch instead of the two ordered. The DON acknowledged the errors and emphasized the need for verifying orders prior to administration.
The facility failed to secure medication carts and protect resident information. Two instances were observed where medication carts were left unlocked and unattended, with computer screens displaying resident information visible to passersby. Both nurses involved acknowledged the importance of securing the carts and screens.
The facility failed to discard expired thickened orange juice containers, allowed a Cook to eat next to the food tray line, observed a Dietary Aide touching their face with gloved hands while handling food, and did not refill a soap dispenser in the kitchen timely. These actions could have led to contamination and foodborne illnesses.
The facility failed to implement TBP and ensure proper use of PPE for a resident with ESBL and VRE, and did not maintain hand sanitizer dispensers in resident rooms. The resident was transported without adherence to TBP protocols, and multiple hand sanitizer dispensers were observed empty, compromising infection control practices.
The facility failed to document resident council meetings and grievances, as required by their policies. Interviews with the Administrator and a CNA revealed that no meeting minutes were taken, and the facility did not maintain a formal grievance log, despite starting resident council meetings in 2023.
Failure to Administer Ordered Medication and Arrange Required Neurology Follow-Up
Penalty
Summary
The facility failed to administer a prescribed medication as ordered for one resident during a medication pass observation. The resident had diagnoses including encephalopathy, anemia, and long-term use of oral hypoglycemic drugs, and had a physician’s order for Megestrol Suspension 400 mg/10 ml, 5 ml by mouth twice daily between 7:00 AM and 9:00 AM and between 7:00 PM and 9:00 PM as an appetite stimulant. During a morning medication pass, an RN prepared and administered multiple medications, including Amlodipine, Metoprolol, Valsartan, Metformin, Heparin, Milk of Magnesia, Azelastine eye drops, and Nystatin Suspension, but did not include the ordered Megestrol Suspension. Later that morning, the RN confirmed that Megestrol had not been given, located the bottle labeled for the resident in the medication cart, and acknowledged that the physician’s order had not been followed and that the orders should have been verified prior to administration. The DON also confirmed that the medication, scheduled for the 7:00 AM to 9:00 AM window, was not administered as ordered, despite facility policy requiring medications to be given in accordance with physician orders. The facility also failed to facilitate a required neurology follow-up appointment for another resident after admission from an acute care hospital. This resident had diagnoses including encephalopathy, multiple sclerosis, epilepsy, and dementia, and the acute care hospital discharge summary instructed that the patient follow up with Neurology within one to two weeks. The Admissions Nurse described the process for new transfers, which includes reviewing the discharge summary and arranging any required medical follow-up, including notifying the physician, arranging transportation, confirming the appointment, and notifying the resident or power of attorney. After reviewing the discharge summary, the Admissions Nurse confirmed that this resident should have received a neurology follow-up appointment within one to two weeks of admission, but this did not occur. The Administrator stated that the expectation for new admissions from an acute care hospital was to follow the hospital discharge instructions and indicated that potential harm or possible death could occur if such instructions were not followed.
Failure to Document Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was appropriately discharged in accordance with their needs and preferences. The resident, who had diagnoses including spondylosis, type 2 diabetes mellitus, hypothyroidism, and hypertension, was admitted with a care plan that required coordinated discharge planning to their home with family. The facility was responsible for assisting the resident and their support person in locating and coordinating post-discharge services, such as home health care, durable medical equipment, oxygen, prescriptions, and other support services. However, documentation revealed that the facility did not provide evidence that the resident was presented with options or assisted in choosing a post-acute care provider that best suited their goals, preferences, needs, and circumstances. Interviews with facility staff indicated that while a form existed for residents to select the facility's preferred home health agency, there was no documented evidence that the resident in question was given a choice or presented with alternative providers. Other residents had signed referral forms for the facility's home health agency, but some did not recall signing them, and the facility did not maintain a list of home health agency providers to offer as options. The Director of Nursing and the Administrator both acknowledged that documentation of discharge planning discussions and options provided was lacking or not consistently recorded in the resident's notes.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) letter to a resident, identified as Resident #99, who was admitted with diagnoses including a fall, right hip fracture, and syncope. The resident's Medicare Part A skilled services episode began on August 30, 2024, and the last covered day for Part A services was September 18, 2024. The resident was discharged home on September 19, 2024. However, the medical record lacked documented evidence that the NOMNC letter was provided to the resident or their representative. On March 19, 2025, the facility's Case Manager was unable to produce evidence that the NOMNC letter was given to the resident. The facility's Administrator confirmed that it was expected to follow CMS guidelines and provide the NOMNC letter three days prior to the end of benefits. The facility's policy stated that the NOMNC should be delivered at least two days before Medicare-covered services end, and the original signed document must be retained in the beneficiary's file. This deficiency resulted in non-compliance with Medicare requirements, potentially affecting the resident's ability to make informed decisions regarding their coverage and care.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to deficiencies in care. One resident, who was at moderate risk for pressure ulcers, did not receive an air mattress as ordered by the physician. Despite the order being documented and verified in the treatment administration record, the air mattress was not placed on the resident's bed, and the wound care nurse did not ensure its delivery or placement. Additionally, a registered nurse documented the air mattress placement without verifying its presence, indicating a lapse in following the care plan. Another resident with a midline catheter did not receive timely dressing changes as per the physician's order. The dressing was observed to be loose and had not been changed for eight days, despite the care plan specifying weekly changes. Similarly, another resident with a midline catheter also did not receive the required dressing change for nine days. This lack of adherence to the care plan for midline care could potentially compromise the residents' health. Furthermore, two residents with nutritional care plans requiring one-on-one feeding assistance did not receive the necessary support during meal times. Observations revealed that staff members were not present to assist these residents, despite their documented need for assistance due to severe protein-calorie malnutrition. Additionally, a resident with a bowel and bladder care plan did not receive an enema as scheduled, resulting in a delay of four days beyond the prescribed intervention. These failures in implementing care plan interventions highlight significant gaps in the facility's adherence to care protocols.
Documentation Failures in Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of care provided to residents, leading to potential compromises in patient safety. For Resident #92, there was a physician order to apply Chlorhexidine (CHG) wipes daily due to a Candida auris infection. However, the treatment administration record (TAR) was inaccurately signed by a Registered Nurse (RN) without verifying the application by Certified Nursing Assistants (CNAs). The CNAs confirmed that regular wipes and soap were used instead of CHG wipes on certain days, and the RN later documented extemporaneous entries in the TAR, which were not present during the initial review. For Residents #17 and #21, there were discrepancies in the documentation of wound care. Both residents had orders for specific wound care treatments, but observations revealed that the dressings on their heels were not changed as documented in the TAR. The wound care nurse admitted to pre-signing treatments before actual administration, leading to inconsistencies between the documented care and the actual condition of the dressings. This practice was acknowledged by the Director of Nursing (DON) as going against the facility's adopted standards of practice. Additionally, there were issues with the documentation of midline dressing changes for Residents #17 and #21. The dressings observed on both residents did not match the dates of documented care in the Medication Administration Record (MAR). The DON confirmed that nurses were not permitted to sign off on treatments without administering them, and the discrepancies in documentation were against professional standards of practice. These documentation failures had the potential to lead to errors in care and hinder continuity of treatment.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide necessary one-on-one feeding assistance to two residents, Resident 21 and Resident 11, who were assessed to require such assistance. Resident 21, diagnosed with metabolic encephalopathy, dementia, and a history of craniotomy, was observed on multiple occasions with meal trays left untouched and no staff present to assist with feeding. Despite a physician's order for one-on-one feeding assistance and instructions to sit the resident up in a chair during meals, these directives were not followed. Certified Nursing Assistants (CNAs) reported that the resident refused to eat, defining refusal as a lack of response from the resident, and did not seek help from other staff or inform the nurse of the refusal. Similarly, Resident 11, with diagnoses including unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required one-on-one feeding assistance. Although a physician's order was in place due to the resident's increased fatigue and poor meal intake, the CNA assigned to the resident was unaware of this requirement and incorrectly believed the resident was independent with eating. This oversight resulted in the resident consuming only a minimal portion of their meal. The Director of Nursing (DON) and Registered Dietician (RD) confirmed the lack of adherence to the feeding assistance orders and the potential impact on the residents' nutritional status. The RD noted that Resident 21 had experienced a two-pound weight loss, which, while not yet significant, could become so if interventions were not implemented. The facility's failure to follow physician orders and ensure proper feeding assistance placed the residents at risk for significant weight loss and malnutrition.
Failure to Administer Prescribed Antimicrobial Wipes
Penalty
Summary
The facility failed to ensure that prescribed antimicrobial wipes were used for the treatment of a multidrug-resistant fungal infection in a resident. The resident, who was admitted with multiple diagnoses including dementia and a Candida auris infection, had a physician order for daily application of Chlorhexidine (CHG) wipes. However, the treatment administration record (TAR) indicated discrepancies in the application of these wipes. On several occasions, the wipes were not applied as ordered, and regular wipes with soap and water were used instead. The RN responsible for documenting the application of the CHG wipes admitted to charting the administration without verifying if the CNAs had actually performed the task. The RN later made extemporaneous entries in the TAR to reflect the actual application status after discovering the oversight. The Director of Nursing confirmed that these actions were inappropriate and could be considered an alteration of medical records. This deficiency in care had the potential to increase the risk of complications for the resident and compromise the overall quality of care within the facility.
Deficiency in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that a physician's order for an air mattress was followed for a resident, leading to a deficiency in pressure ulcer care. The resident, who was at moderate risk for pressure ulcers due to multiple co-morbidities, did not have the ordered air mattress in place. Despite the physician's order and care plan specifying the need for an air mattress, it was not delivered or placed on the resident's bed. The wound care nurse acknowledged the oversight and the failure to verify the placement of the air mattress, which was documented as verified in the treatment administration record without actual confirmation. Additionally, the facility did not provide wound care treatment as per physician's orders for two residents. One resident reported inconsistent care for heel ulcers and a coccyx wound, with the treatment administration record showing missed wound care on several dates. The registered nurse and wound care nurse both acknowledged the discrepancies in documentation and the failure to administer wound care as scheduled. The wound care nurse admitted to pre-signing treatments that had not yet been administered, leading to inaccurate documentation. For another resident, the facility also failed to administer wound care as ordered, with the treatment administration record indicating missed treatments. The wound care nurse and registered nurse both confirmed the lack of documentation and the practice of pre-signing treatments. The Director of Nursing acknowledged the unacceptable practice of signing off on treatments that were not administered and the misalignment between observed dressings and documented care.
Failure to Follow Bowel Protocol for Constipated Resident
Penalty
Summary
The facility failed to follow its bowel protocol for a resident who was constipated, leading to a deficiency in care. The resident, who had a history of ulcerative colitis and diverticulitis, had not had a bowel movement since March 11, 2025. Despite having a physician's order for a Fleet Enema to be administered on the fifth day without a bowel movement, the enema was neither offered nor administered by March 20, 2025, which was nine days without a bowel movement. The facility's bowel protocol, known as the Bowel Brigade, was not followed, as the resident did not receive the prescribed interventions, including Milk of Magnesia and Dulcolax suppository, in a timely manner. The resident's family member, who visited daily, expressed concerns about the lack of bowel movements and was not informed about the bowel protocol or the physician's order for an enema. The family member was also not provided with the results of a KUB test, which showed mild increased feces throughout the colon, despite requesting them. The Infection Preventionist confirmed that the enema was not administered as per the protocol, and the Director of Nursing acknowledged that the facility's standing orders were not followed. This oversight placed the resident at risk for bowel complications.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to follow physician's orders to provide one-on-one feeding assistance for two residents, leading to a risk of significant weight loss and malnutrition. Resident 21, who was admitted with diagnoses including metabolic encephalopathy and dementia, was observed on multiple occasions with meal trays left untouched and without staff assistance, despite a clear order for 1:1 feeding assistance. The resident was dependent on staff for eating, and the lack of assistance was attributed to CNAs being too busy or shy to ask for help. The resident's condition improved when seated in a chair, but this intervention was not consistently implemented. Similarly, Resident 11, diagnosed with unspecified dementia and severe protein-calorie malnutrition, was also not provided with the required 1:1 feeding assistance. The resident was observed with a meal tray in front but no staff present to assist, despite a physician's order due to the resident's increased fatigue and poor meal intake. The DON confirmed that the physician's orders were not followed, and the CNAs failed to report meal refusals to the nurse, preventing further attempts to assist the residents. The Registered Dietician noted that both residents had issues with alertness and poor consumption, necessitating the 1:1 feeding assistance. The RD was not informed of the lack of compliance with the feeding orders, which could potentially lead to significant weight loss. The facility's policy required necessary services to maintain good nutrition for residents unable to carry out activities of daily living, but this was not adhered to in the cases of Residents 21 and 11.
Deficient Midline Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure proper justification and maintenance of midline catheters for two residents, leading to potential risks of complications such as occlusion and infection. Resident 17 was admitted with a midline catheter in the right upper arm, but there was no documented evidence of a physician's clarification order regarding whether the midline should be maintained or removed. The midline dressing was observed to be dated 03/10/2025, with ends coming loose, despite a physician's order for weekly dressing changes. The Medication Administration Record (MAR) inaccurately documented a dressing change on 03/16/2025, which did not align with the actual observation. The Infection Preventionist confirmed the lack of a nurse-physician discussion about the midline's status. Resident 21 was admitted with a double lumen midline used for IV electrolyte administration. The midline dressing was dated 03/09/2025, with ends coming loose, and the MAR inaccurately documented care on 03/16/2025. The Clinical Nurse Manager confirmed the discrepancy and described the dressing as not appearing new. The Director of Nursing acknowledged the lack of a specific midline policy and confirmed that the facility followed the PICC Dressing Change policy, which required dressings to be labeled with date, time, and initials. The failure to perform midline care as documented placed residents at risk for infection, as noted by the Director of Nursing.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter and an intravenous midline catheter. The resident, who was admitted with serious conditions including septic shock and pneumonia, was placed on enhanced barrier precautions as per a physician's order. However, during an observation, a therapist did not adhere to these precautions while providing care. Specifically, the therapist used gloves but failed to wear a gown when emptying the urinary bag connected to the resident's catheter. This oversight was confirmed by a registered nurse who acknowledged that the therapist should have used both gloves and a gown during the procedure. The facility's infection preventionist nurse also reiterated that enhanced barrier precautions, which include the use of gloves and gowns, should have been followed during the care of the resident's indwelling catheter. The facility's policy, aligned with CDC guidelines, mandates these precautions for residents with indwelling medical devices to prevent the spread of multi-drug-resistant organisms.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper dialysis care and communication for two residents requiring such services. For Resident 28, the facility did not maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The facility driver, who transported Resident 28, did not have the dialysis communication paper post-dialysis treatment and was unaware of the resident's contact isolation precautions, leading to potential cross-contamination. Additionally, the facility did not communicate Resident 28's infection status to the dialysis center, which could have compromised infection control measures at the dialysis center and during transport. For Resident 27, the facility also failed to maintain documented evidence of communication or collaboration of care between the facility and the dialysis center. The resident's medical records lacked documentation of pre- and post-dialysis vital signs and weights, as well as care orders and management for the resident's arteriovenous fistula (AVF). The facility did not obtain, transcribe, or implement care orders for monitoring the AVF for signs of bleeding, infection, and drainage until several days after the resident's admission. The Infection Preventionist and Director of Nursing confirmed the lack of communication and documentation regarding dialysis care for both residents. The facility's policies and agreements with the dialysis center emphasized the importance of communication and collaboration of care, but these were not followed, leading to potential risks for the residents' health and safety.
Failure to Obtain Physician Order and Care Plan for Splint
Penalty
Summary
The facility failed to ensure a physician order was obtained for the use of a splint, care orders on how to manage the resident's splint were transcribed and implemented, and a care plan was initiated for one resident. The resident was admitted with a wrist fracture and had a splint in place, but the medical records lacked documented evidence of a physician's order, instructions for managing the splint, and a care plan. The resident's splint was identified during an evaluation by the Certified Occupational Therapy Assistant, but it was not included in the therapy treatment plan, and the nursing staff did not obtain the necessary physician order or care plan for the splint's management. The Director of Nursing confirmed that the admission nurse was responsible for obtaining the orders for the splint, which were missed and not transcribed. The splint was in place at all times, but no care orders had been obtained or transcribed, and no care plan had been initiated. The facility's Splint Management Policy documented that splints would be applied per physician orders, but this was not followed in the case of the resident, leading to the deficiency.
Failure to Obtain Physician's Order for IV Insertion and Care
Penalty
Summary
The facility failed to ensure a physician's order for peripheral intravenous (IV) insertion and care orders were obtained, transcribed, and implemented for one resident. Resident 138 was admitted with diagnoses including urinary tract infection, sepsis, and dehydration. The nursing progress notes documented the initiation of IV fluids, but there was no documented evidence of a physician's order for the IV insertion or related care. On observation, the IV heplock appeared old and undated, with the dressing edges peeling off, and the resident reported that the IV access had been in place for four days without use. A registered nurse confirmed the absence of an order for IV access insertion or related care and noted that the IV heplock was old and the dressing was undated and peeling off. The resource nurse and the director of nursing indicated that any IV access required an order for insertion and management, including flushing and monitoring of the insertion site. Facility policies also documented the need for a physician's order for IV therapy, maintenance, and removal of any peripheral IV catheter that is no longer essential.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to ensure the Oxygen (O2) flow rate was followed as ordered or the titration rate and frequency of the administration were clarified for Resident 137. Resident 137 was admitted with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic pulmonary edema. The physician's order specified O2 per nasal cannula at 2 liters per minute (LPM) to maintain SpO2 of more than 90%, with the possibility to titrate or discontinue O2 as tolerated. However, the order did not specify whether the O2 should be administered continuously or as needed, nor did it provide titration rate parameters. Observations on multiple occasions revealed that Resident 137 was receiving O2 at 4 LPM, contrary to the prescribed 2 LPM. The resident was unsure of the amount of O2 being received and indicated dependency on O2, with no signs of respiratory distress noted during the observations. A Registered Nurse (RN) confirmed that the O2 was flowing at 4 LPM and acknowledged that the active order did not specify continuous administration or titration parameters. The RN explained that the physician's order should have been followed to avoid potential O2 toxicity. The Director of Nursing (DON) also indicated that O2 administration required an order and that staff were expected to verify and follow these orders. The DON acknowledged that the titration parameters and frequency should have been clarified. The facility's Oxygen Administration policy stated that O2 should be administered in accordance with a physician's order, with appropriate safety precautions to ensure safe administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was below five percent, resulting in an error rate of 6.25%. One incident involved a registered nurse administering a standard iron tablet instead of the prescribed delayed-release iron tablet to a resident. The nurse was uncertain about the difference between the two forms, and the pharmacist later confirmed that the standard iron tablet has quicker absorption compared to the delayed-release form, which releases iron gradually in the intestines. The Director of Nursing acknowledged the error and indicated that the correct dosage form should have been verified to prevent such medication errors. Another incident involved a registered nurse preparing and offering a Lidocaine 4% patch to a resident, who preferred to receive it later after therapy. When the patch was eventually administered, only one patch was applied instead of the two patches ordered by the physician. The Director of Nursing indicated that licensed nurses were expected to verify the order prior to administration to ensure the correct dosage was administered. The facility's policy on medication errors emphasized following the six rights of medication administration to minimize errors.
Unsecured Medication Carts and Resident Information
Penalty
Summary
The facility failed to ensure resident personal information was protected and that medication carts were secured. On 05/22/2024 at 2:10 PM, a medication cart near a resident's room was observed unattended with the computer screen on, displaying resident pictures and names, and the cart was unlocked. The nurse admitted to leaving the cart and computer screen unattended while obtaining supplies. Similarly, on 05/22/2024 at 8:21 AM, a registered nurse left a medication cart unlocked and unattended in the hallway while administering medication in a resident's room. The computer screen on the cart was also left on, displaying resident information, and was visible to anyone passing by. Both nurses acknowledged the importance of locking the medication cart and securing the computer screen to protect resident privacy and prevent unauthorized access to medications. The Director of Nursing confirmed that the medication carts should have been locked when unattended and the computer screens secured. The facility's policies on medication storage and administration indicated that medication carts should be locked when out of view and that electronic medication administration records should be logged out before leaving the cart.
Multiple Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to discard five expired thickened orange juice containers stored in the nourishment room. The expired containers were observed on two separate occasions, and the Nutritional Services Director confirmed the expiration dates and acknowledged that expired food items needed to be discarded to prevent foodborne illnesses. Additionally, a Cook was observed eating next to the food tray line, which is against the facility's policy. The Cook admitted to the mistake and explained that staff were supposed to eat away from the kitchen to prevent contamination. The Nutritional Services Director confirmed that staff were not to eat in the food preparation area according to the facility's policy. A Dietary Aide was observed touching their face and nose with gloved hands while handling food during the tray line. The Dietary Aide acknowledged the error and explained that, according to policy, they should have washed their hands and changed gloves after touching their face to prevent contamination. Furthermore, a soap dispenser at the sink closest to the kitchen entrance was observed empty on two separate occasions. The Nutritional Services Director confirmed the soap dispenser was empty and reported that housekeeping had been notified to provide soap. The Housekeeping Supervisor explained that staff were to request refills from housekeeping, and it was important to refill soap dispensers quickly to prevent any infection control issues.
Failure to Implement TBP and Maintain Hand Sanitizer Dispensers
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) and ensure proper use of personal protective equipment (PPE) for a resident diagnosed with ESBL and VRE. The resident, who required strict contact isolation, was transported to and from a dialysis center without adherence to TBP protocols. The facility driver, unaware of the resident's contact precautions, did not clean hands or wear PPE when assisting the resident, despite the presence of precaution signage. This lapse in protocol was confirmed by both a Certified Nursing Assistant and a Registered Nurse, who acknowledged the necessity of PPE and hand hygiene to prevent contamination and infection spread. Additionally, the facility did not maintain hand sanitizer dispensers in resident rooms, which were observed empty on multiple occasions. This issue was confirmed by a nurse and the Housekeeping Supervisor, who explained that staff were responsible for requesting refills. The lack of readily available hand sanitizer compromised the ability of staff and visitors to perform necessary hand hygiene, particularly in rooms with enhanced barrier precautions. The facility's Alcohol-Based Hand Sanitizer Policy emphasized the importance of hand hygiene to prevent infection transmission, highlighting a significant deficiency in infection control practices.
Failure to Document Resident Council Meetings and Grievances
Penalty
Summary
The facility failed to ensure a written record of resident council meetings was kept, documenting any responses to concerns raised by the Resident Council group, and a report of actions taken and the rationale to the Resident Council. Additionally, the facility did not maintain a written record of grievances, documenting any responses and the rationale for responses to grievances regarding resident issues or grievances concerning care and life in the facility. This deficiency was identified during interviews with the Administrator and a Certified Nursing Assistant (CNA), who confirmed that no meeting minutes were taken and kept by the facility, and that the facility did not have a formal grievance log. The Administrator admitted that the facility was not good at keeping up with the logs and may have copies of resident grievances. The CNA explained that the Ombudsman suggested regular monthly resident council meetings be held, and that the facility started having resident council meetings in 2023. However, the facility did not document these meetings or maintain a grievance log. The facility's Resident's Rights policy and Grievance Policy both require documentation of grievances and responses, but the facility failed to comply with these policies.
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Illustrative
What surveyors actually found near you
We read the 555 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of South Las Vegas | 2.8 mi | ★★★★★ | 6 | 2 |
| Harmon Hospital - Snf | 2.8 mi | ★★★★★ | 14 | 0 |
| Trellis Paradise | 2.8 mi | ★★★★★ | 2 | 0 |
| Tlc Care Center | 3.5 mi | ★★★★★ | 6 | 0 |
| Premier Health & Rehabilitation Center Of Lv, Lp | 4 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.